The Other End of Shyness

Do you privately shake with nerves or shyly blush when the attention is on you? Most people experience some form of shyness but others are so immobilised by the fear of being judged negatively that they can barely function. Social phobia is the third most common mental illness after depression and substance abuse. We hear about one woman's 20 year struggle with social anxiety and some recent scientific findings about the brain activity associated with this disorder.

Transcript

Lynne Malcolm: Hello, Lynne Malcolm here on ABC Radio National with All in the Mind. Today  the other end of shyness.

[Excerpt: Little Voice]

From the film Little Voice in which the painfully shy LV emerges as a star singer and finds her true self and her big voice. We all experience shyness to some extent, we're social beings and we like to be liked. But some people are so afraid of being negatively judged by others that they can barely function. It's a condition known as Social Anxiety Disorder. Sue Cleland lived this nightmare for 20 years and she became aware of it as a teenager.

Sue Cleland: I had my first panic attack when I was 13 years of age and I was with some friends and we went into a shop and I had to pull out some money and just the mere fact of doing that I felt as though the person was judging me behind the counter and I had a panic attack. And I had no idea what was going on in my body but it was the most frightening experience I'd ever had.

So I guess the fear really took off from that point. When I was in a situation in which I was the centre of attention the panic attack was worse and in particular the anticipatory anxiety which is worrying weeks or months in advance about something that I had to do in which I was going to be the centre of attention. And going to university I think was a particularly very difficult time for me. Initially I used to pick subjects where I didn't have to do any presentations. When I had to do a presentation I dreaded it with such intense fear that I would always be sick the morning beforehand and throughout the presentations I knew I was shaking, I had a lot of feedback from people who told me that I was, which just intensified my fear even further and reconfirmed that yes, people could see this and everyone thinks, you know, I'm stupid and I'm weak and I can't cope.

When anyone spoke to me I felt an intense heat in my face rise and I had no idea why that was happening, but the fear of it happening was enough to actually turn on that response.

Lynne Malcolm: So what were the thought processes that went on?

Sue Cleland: People are judging me, people are criticising me, people think I'm not good enough, people think I'm different to everyone else and that is the basis of social anxiety.

Lisa Lampe: We can identify social anxieties on a spectrum; from shyness, which we would consider pretty normal, moving on up to people who experience more than the usual degree of anxiety when they're interacting with other people or having to do things in front of other people. And all the way up to a condition that we call the avoidant personality disorder, where people are so disabled and inhibited by their fear of being rejected by other people that they may virtually not interact with other people at all, or in a very minimal way.

Lynne Malcolm: Psychiatrist Dr Lisa Lampe has studied social anxiety disorder for many years. She also has a clinical practice and we'll hear more about her treatment methods later, as well as some recent neurobiological findings.

A community survey a few years ago showed that 2.3% of the Australian population suffer from social anxiety disorder and it's the third most common mental illness after depression and substance abuse. Women are affected only slightly more than men and in the majority of cases it hits early in life. So people often suffer for a long time before they get help, as we just heard from Sue Cleland.

Lisa Lampe: Bill says I've never felt I've fitted in. Right from primary school I was always a loner, I never had any friends, I just felt different from the other kids. At high school it only got worse, he held back, he never did anything outside of school hours, he could never speak up in class, he may or may not have gone to university but probably didn't because he found it overwhelming and dropped out. He's taken jobs that were well beneath his intelligence level because he just felt so intensely anxious in any type of interaction with other people, feeling that people didn't like him, that they thought that somehow he just wasn't quite as good as them. To the point where Bill himself has come to believe that somehow he's not quite as good as other people.

So by the time he comes to see me he's depressed, he's often drinking too much because the only way he can interact with anybody socially is to have a good few drinks first and he's really quite miserable and lonely. At the age of perhaps say 40 he's still with his parents, has had no serious relationships and is really very unhappy. And I'm sorry to say that there's quite a lot of people that would have that sort of story.

Lynne Malcolm: And Sue Cleland explains how this disorder was destroying her life.

Sue Cleland: There was the physical symptoms of course, when you think fear to a very high level you turn on that response in your body, the anxiety or the fight and flight response. So you get all the symptoms of that which includes trembling, shaking, hot flushes, blushing  that was a very big one for me  sweating, lots of feelings of agitation. And I guess when you experience those then you will go to any length you possibly can to avoid situations in which you feel that you're going to experience those symptoms.

I started to develop a lot of avoidant behaviours and what I would do is I'd develop friendships but as soon as they started to get close to me I would move away from them because of the fear that they would actually find out that I had this terrible anxiety. So that was one of the things in which I did, I just kept moving and moving and I actually started moving house a lot and in 12 years I moved house 18 times. I started to use a lot of alcohol from an early age to assist me to manage my fears. I found when I drank I didn't have any of those physical symptoms and I could more easily go out and interact with people so alcohol really did become a bit of a crutch for me and just caused a lot more problems in my life and with relationships.

Lynne Malcolm: So did you find that you were actually happiest when you were on your own?

Sue Cleland: No, it's like a double edged sword because you really crave that companionship of people, you know to feel close, to feel this sort of sense of belonging and to have the meaningful relationships and friendships. But when you're actually in them you don't want to be there, you're afraid of actually being there with people. So it's this real double-edged sword between really wanting it and really being afraid of it. No one actually knew what I was going through until I was 30 and by the time I was 30 I'd moved completely away from all my friends. I made out to everyone that everything was fine, I was drinking very heavily, I was also using a lot of marihuana in the evenings just to...I guess for escapism and everything just fell apart. I felt like I was at the end of my career, I couldn't move forward in my career because it meant I would have to have done management meetings and I couldn't speak in that public sort of role.

So the realisation of that was enough to sort of tip me over the edge and at that point I went to hospital for three weeks and that's when my family and all my friends found out what had been going on since the time I was about 10.

Lynne Malcolm: Sue went on to get treatment for her disorder and now has a much more satisfying life. In fact her sometimes frustrating path to recovery led her to set up an information network called Social Anxiety Australia and she also runs treatment programs for individuals and groups. But according to Dr Lisa Lampe who was involved in an Australian survey of the condition, Sue Cleland is in a minority.

Lisa Lampe: We found a very distressing piece of information from our community survey which was that only about 20% of people who have social anxiety disorder actually get treatment for it. And this seems to be because people feel that they ought to be able to handle it themselves or they think that it's just the way they are and nothing can be done about it. And the very important message I'd like to get across to people is that there are effective treatments for it. You can learn to be less anxious with people and more comfortable interacting with people.

Lynne Malcolm: And I guess too one of the things that stops people seeking treatment is the very problem that they have and that's a fear of interacting with people?

Lisa Lampe: That's quite true and unfortunately many people are ashamed and embarrassed of the fact that they don't feel comfortable socially. I think most people once they're at the doctors and they find that the doctor has heard about it before, understands what they're talking about, probably feel a sense of relief. But it's probably difficult to make that first step.

Lynne Malcolm: I suppose there's a sense that perhaps being shy has an evolutionary function that it could be a self protective mechanism?

Lisa Lampe: That there's no doubt that humans are social creatures, you know we needed to have the support of other members of the tribe to survive. In all of us there is a need to be liked, to be accepted. But what happens when people have a social anxiety disorder is  if you have that normal desire to be liked and accepted  starts to become something that almost rules their life plus they start to misinterpret other people's reactions. They often perceive criticism where none was intended and what our studies show us quite interestingly is that a lot of social cues, a lot of social interactions are what we call ambiguous.

You might raise your eyebrows while I'm talking to you and that could mean anything, that could mean you're interested, that could mean you didn't quite understand, that could mean you're not sure that I'm telling the truth. It could mean anything but if I have a social anxiety I'm more likely to make a negative interpretation of that. And you can see that that becomes very problematic in trying to live your life because much of the time really we don't know for sure what people think about us. And life works best if you assume the best, but unfortunately people with social anxiety very frequently assume the worse and that only makes them more anxious, they then become preoccupied with what they feel is a negative perception that other people are getting of them and that further inhibits their ability to relax and be themselves and interact with people.

Lynne Malcolm: Okay, we'll come to the treatments but before that what are the causes?

Lisa Lampe: That's a very vexed question and we really don't know for sure. A number of overseas studies have tried to look at the question and one of the ways they've looked at it has been looking at twins. To see, you know, if one twin has it how likely is it that the other has it? And in fact those results have suggested that there is a very strong genetic component, that perhaps somewhere between 40% to 60% of the variance of why you get social phobia is explained by genetic factors. And indeed I can tell you in my clinical practice, when I ask people have one or other of your parents got social anxiety then the answer is very often yes.

Now we've also looked at how does experience impact  and interestingly it doesn't seem to be the case that if you were separated from your parents, or had those sort of separation type experiences, that that's particularly likely to cause a problem. But of course people do often report that they had what they experienced as traumatic events at school, singularly embarrassing or upsetting events. But in interpreting that, we always have to be careful because of course many of us can report embarrassing incidents from school and it may be that if you're already quite sensitive then those things impact on you more strongly. So they may be don't cause you social anxiety disorder but they could perhaps reinforce a tendency to be hypersensitive.

And the most important thing is it doesn't seem that there is a strong causative factor in how your parents treated you. So you know I think it's really important for adults that have this disorder, that worry about, you know, will I cause it in my children? Well look  you might pass it on in your genes but being aware of it yourself and getting treatment for it, if one of your children does get it, you're probably in a much better position to help them overcome it at an early stage.

Sue Cleland: I believe when I was born I was born a very sensitive child and a child that always tended to take things to heart and tended to over-analyse things in my life. And then as a young child I had particular experiences, none of them were exceptionally traumatic but I grew up in a family in which I felt as though I was criticised quite a bit and there were fairly high expectations placed on me. Not that I think my parents had any idea of the impact that was having on me, but because of my sensitivity I tended to take that very personally and tended to feel from a very young age that I wasn't good enough. And that just manifested over the years to the point where when I was a teenager I had developed incredibly low self-esteem, believing that whatever I said, whatever I did would be criticised or scrutinised and it would always be wrong.

Lynne Malcolm: This is All in the Mind on ABC Radio National, I'm Lynne Malcolm and shortly we'll hear about treatments for social anxiety disorder. But first a recent scientific finding which confirms that those who suffer its symptoms have a particular type of activity going on in the region of the brain known as the amygdala.

Dr Pradeep Nathan from Monash University along with Dr Luan Phan from the University of Chicago recent published their study in the Journal of Biological Psychiatry. Pradeep Nathan.

Pradeep Nathan: Part of the brain called the amygdala has been shown to be important for processing threat and fear and there are some studies recently done to show that the amygdala may be hyper responsive or exaggerated in social anxiety disorder in response to viewing facial stimuli. So in this study we aim to look at the relationship between the amygdala response to facial stimuli and their clinical symptoms. So we imaged using a technique called functional magnetic resonance imaging, which basically measures blood flow to areas of the brain that require an increase in brain activity and require energy to that area so usually there's an increase in blood flow to those areas.

Lynne Malcolm: So the study involved scanning the brains of two groups of people while they were shown pictures of faces displaying a range of different emotions. One group had social anxiety disorder, the other did not.

Pradeep Nathan: Both patients and controls were shown a series of different facial expressions of emotion ranging from happy, sad, disgust and fear. What we did was we grouped the harsh faces  which we defined as angry, fear and disgust because all three of these facial expressions can activate the amygdala more so than neutral faces or happy faces. So we compared the brain's response to these harsh faces relative to the brain's response to neutral and happy faces. And we found that patients with generalised social anxiety disorder had an exaggerated amygdala response to these harsh faces compared to neutral or compared to happy faces.

Lynne Malcolm: So what are the conclusions and the implications that you can draw from that?

Pradeep Nathan: Well the most interesting part of the finding was that the response of the amygdala to these harsh faces correlated with their clinical symptoms which suggests that the amygdala response to faces or inter-personal threat could be a marker of their disease severity. And this suggests that techniques like functional magnetic resonance imaging could be used to examine the severity of the disease in a more objective way than the standard method of questionnaire based measures.

Lynne Malcolm: So in a way it's confirmation, it's physical confirmation of the disorder?

Pradeep Nathan: Yes, it is a confirmation there is a biological origin, there is a neural circuitry that his hyper-responsive and perhaps it may also suggest ways to treat the illness. For example if there are therapies of pharmacological treatments that could suppress amygdala function then that may be a way of not only looking at how drugs are affective in treating this disorder but you can perhaps use imaging as a way of following up the patients while they're being treated to examine the effectiveness of medication or psychological treatments.

Lynne Malcolm: Dr Pradeep Nathan from the Monash Centre for Brain and Behaviour. And Dr Nathan's group at Monash plan further studies, in particular to test a treatment involving the hormone oxytocin in the form of a nasal spray which may give acute relief from the symptoms. Check the All in the Mind website if you'd like to know more about that work.

But what's the best way to treat social anxiety disorder now? Dr Lisa Lampe has researched and assessed the effectiveness of a range of treatments.

Lisa Lampe: We know that there's two types of treatment that can be effective. There's been a lot of study put into medication treatment of social anxiety disorder and psychological treatments of social anxiety disorder. The psychological treatment that is effective is a type called cognitive behaviour therapy or CBT for short. And what that's about is saying that it's the way we think about ourselves and our interactions with other people that are likely to make us anxious.

So if I assume the worst, if I jump to conclusions that you don't like me or that you're critical when really you're not, if I assume that you think that my blushing or sweating is grossly abnormal and makes me an oddity, or that you even notice, then that always is going to make me more anxious. So part of our cognitive work in cognitive behaviour therapy tries to help people perhaps put things in more perspective, to try to think more like people who aren't excessively anxious, to try to assume the positive instead of the negative. And then we must have a behavioural component.

So where people have been avoiding social situations unfortunately the more you avoid it the less your confidence becomes because you never have a chance to show yourself that you can actually manage that situation.

Now having said that I would really encourage people to do that exposure if you like, to confront those situations with help. And the reason for that is that many people do push themselves to talk out in a group, go to that party, but then they go home and they say oh that was terrible, nobody liked me, it was a disaster. Of course they're not going to get more confidence from that and that's why the cognitive part is so important to do with the behavioural part, that you've got to go home and say well, that wasn't too bad, I managed to talk to a couple of people and stop focussing on all the pauses, or the awkward moments and focus on the successes instead. And often people need a bit of professional help to help them get the hang of retraining the way they think about things.

So that's cognitive behaviour therapy and we know that that therapy can create about a one standard deviation change. Now  what does that mean? Well that means we can move you back about a notch so if you're extremely anxious we can make you still moderately anxious but less anxious. If you start out only moderately anxious we can probably help you achieve normal levels of social anxiety. And there is a normal level of social anxiety, we all get anxious sometimes.

And the important thing about cognitive behaviour therapy is that the benefits persist over time. So there have been a few studies that have followed a number of people up for even up to five years and found that largely they maintain those benefits. So it is hard work because you're confronting your anxiety, it does make you a bit more anxious in the short term, but we do it in a step by step way so it's not too frightening. And the point is if you can stick at it, it works and it will keep working. So that's psychological treatments.

Lynne Malcolm: So what about medication? It's been found that tranquilisers can work but Lisa Lampe says they are now not considered the first choice of treatment. More recently another class of drugs, antidepressants, have been shown to be more effective.

Lisa Lampe: If you're going to use medication, what's considered the most appropriate first line medication is actually an antidepressant. Now that confuses everybody because lots of people say well I'm not depressed, and it's a bit unfortunate the name, I guess, because they were initially developed for depression. But as time went by it was discovered that many antidepressants are actually very effective for treating anxiety as well.

A couple of key points about them is that they actually take a bit longer to work than they do for depression. So many people sort of try them and give up on them, whereas my experience and that of other people who treat a lot of anxiety shows that it can easily take six weeks or more. And the antidepressants seem to help people become less anxious, less concerned about their social anxiety and it seems to help them take the steps to get out and do things. And it has about equivalent effectiveness to cognitive behaviour therapy, so the two treatments are fairly equivalent.

However, the antidepressants only seem to work as long as you take them. But I do think there's a place for antidepressants because some people in fact who have had social anxiety for much of their lives do actually become very depressed. I mean as you can imagine if you were longing to be able to have satisfying relationships with other people and you can't bring yourself to do it because of your anxiety, it can be very depressing. And often when I do see someone who's quite depressed at the time I will start them on antidepressants because it's very hard to do cognitive behaviour therapy if you're depressed at the same time. Because it's too hard to think creatively, take chances, when you're just unremittingly negative about things. So I'll often use both antidepressants and cognitive behaviour therapy and then by learning the cognitive behaviour therapy the aim is that that will stay with you and then later we can perhaps discontinue the antidepressants but you'll have your CBT skills to help you keep fighting the problem.

But I think personally that probably the advances in treatment that have been made recently have actually come more from trying different cognitive behavioural approaches. And just to give you an example, we've recently learned how important the role of what we call self-focussed attention is. And we know that the average person who isn't excessively socially anxious goes into a party or a gathering and initially is self-conscious but quickly you look around the room, who's there, what have they got to eat, what music are they playing and they relax. And we know that the person with excessive social anxiety goes into the room is self-conscious and it only gets worse. Oh am I sweating, am I blushing have they noticed, oh that sounded stupid, why did I say that?

So that experimental finding, that where you put your attention can hugely affect your anxiety level, would be quite a breakthrough in therapy. And I've found that that advice to people alone, keep your attention out there and off yourself, has made a huge difference to the outcome of treatment. So I think the neurobiology is fascinating but it's still early days for that. So I think we've got to have clinical research and neurobiological research.

Lynne Malcolm: Dr Lisa Lampe, and there are already a number of studies to show that cognitive behavioural therapy can actually change the brain circuitry. And the final words from Lisa Lampe and Sue Cleland.

Lisa Lampe: I guess I'd really like to encourage people to not feel that they're some sort of freak if they have this problem, where either they feel too anxious to interact with other people, or they worry too much about how they come across. But to say lots of other people have this problem, you can get help for it, you can learn some strategies to help you feel more comfortable socially and be able to live that type of life that you really want to.

Lynne Malcolm: Dr Lampe, thank you very much. Sue are you completely cured of the disorder now?

Sue Cleland: Yes, in terms of how it affected my live. I talk about recovery in terms of management, like anxiety is an emotion that everyone experiences and some people experience it to a much greater degree. For those who experience it to that great degree there is help to actually assist you to only turn on the response when it's required  which is, you know, if you walk in front of a speeding car. So in terms of cure I don't believe I will ever be cured, if you like, because I will always have the ability to turn on the response; but I have it at a level now where I can manage it, where I don't turn it on unless it's actually warranted. So life has become just easy and pleasurable for me again.

Lynne Malcolm: As an example, coming in to do this interview today  I guess there would have been a time when you would have been extremely anxious about doing that?

Sue Cleland: Lynne, I just wouldn't have done it. I would not have even considered it.

Lynne Malcolm: And thanks to Sue Cleland for sharing her story with us today. For links to further information on social anxiety disorder go to the All in the Mind website at abc.net.au/rn and there you can also download the audio of the last four programs and you can read the transcripts as well.

Thanks to Pauline Newman for today's production and to sound engineer Angus Kingston. I'm Lynne Malcolm, I hope you can join me next week for All in the Mind.

Guests

Sue Cleland

Social Worker who suffered from Social Anxiety Disorder for 20 years before she got treatment.

Dr Pradeep Nathan

Monash University's Centre for Brain and Behaviour Department of Physiology

Dr Lisa Lampe

Psychiatrist - consultant in Private Practice SydneyVisiting Medical Officer St. Vincents Hospital SydneyConjoint Lecturer University of New South Wales Clinical Research Unit for Anxiety and Depression

Publications

Title

Social Phobia in the Australian National Survey of Mental Health and Well Being (NSMHWB)

Author

L. Lampe, T.Slade, C.Issakidis and G.Andrews

Publisher

Psychological Medicine, 2003, 33, 637-646

Title

Association between Amygdala Hyperactivity to Harsh Faces and Severity of Social Anxiety in Generalized Social Phobia